**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an environment free of falls for one resident (Resident 1) of three sampled residents when the facility:1. Did not initiate a person-centered care plan for Resident 1's fall risk prior to [DATE]; and,2. Did not analyze Resident 1's risk for a fall after worsening edema (swelling from an accumulation of fluid in the body's tissues) and possible deep vein thrombosis (DVT, a blood clot in a deep vein which can cause pain and swelling) in her lower legs.These failures contributed to Resident 1 sustaining a left fibula (one of the two bones in the calf) [NAME] fracture (a break of the upper fibula usually caused by twisting or forceful rotation of the ankle) from a fall. Cross reference F557.Findings:1. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of venous insufficiency (a condition where the veins in the legs have difficulty in returning blood to the heart, often causing swelling and pain), morbid obesity (a disorder that involves having too much body fat, which increases the risk of serious health problems such as joint pain from excess weight), and personality disorder (a mental health condition characterized where people have a pattern of seeing themselves and reacting to other others in ways that cause problems). A review of Resident 1's care plans on [DATE] indicated the following:-On [DATE] a care plan was initiated for Resident 1's limited ability to perform Activities of Daily Living (ADL, basic tasks performed by individuals to maintain their daily life) related to her limited mobility and morbid obesity. Resident 1's goal was to demonstrate the appropriate use of adaptive devices (equipment used to help people perform daily activities, such as a cane or walker) to increase her ability with transfers or toilet use; however, no specific adaptive device was indicated. The interventions listed to assist Resident 1 to meet this goal included, TRANSFER: The resident has requires [sic] 1 staff assistance with transfers.[Revised] on [DATE].[and] TOILET USE: The resident has requires [sic] 1 staff participation to use toilet.[Revised] on [DATE].-On [DATE] a care plan was initiated for Resident 1's moderate risk for falls related to gait and balance problems. Resident 1's goal was to be free of serious injury through the review date of [DATE]. The last time this care plan was updated was on [DATE].-On [DATE] a care plan was initiated for Resident 1's risk for breakdown immobility related to an alteration in peripheral tissue perfusion (a reduction or impairment in blood flow to the tissues of the arms and legs, preventing them from receiving enough oxygen) due to chronic venous insufficiency. Staff were expected to implement interventions which included checking the lower extremities for pain, cramping, and weakness in one or both legs. This care plan was revised on [DATE].- On [DATE] a care plan was initiated for Resident 1's potential to demonstrate.behaviors r/t [related to] poor impulse control which indicated staff was expected to Assess and anticipate resident's needs.toileting needs, comfort level, body positioning, pain etc.-There was no documented evidence that a care plan for Resident 1's risk of falls was updated between [DATE] and [DATE].A review of Resident 1's quarterly risk data collection tool dated [DATE] at 6:37 p.m., [DATE] at 11:51 a.m., [DATE] at 11:23 a.m., and [DATE] at 5:33 p.m. indicated, .is resident at risk for falls? Yes.A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated [DATE] indicated:-Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment used to measure cognition (a person's ability to process information and understanding)) score of 15 which indicated Resident 1's cognition was intact;-Resident 1 normally used a walker as a mobility device; and,-Resident 1 required setup or clean-up assistance (meaning the helper assisted only prior to or following the activity) when transferring from a sitting to standing position and during toilet transfers.During an interview on [DATE] at 12:43 p.m., the Director of Nursing (DON) stated nursing staff did not consider Resident 1 at risk of falls prior to [DATE] and acknowledged Resident 1's care plan regarding her fall risk was initiated on the same day Resident 1 fell on [DATE].2. A review of Resident 1's order summary report dated [DATE] to [DATE] indicated the following physician's orders:-On [DATE] an order was placed for staff to encourage Resident 1 to elevate her legs using the recliner every shift for swelling; and,-On [DATE] an order was placed for a Left Duplex Scan (a non-invasive ultrasound test that uses sound waves to create images of blood vessels and assess blood flow) for veins in extremity unilateral (one side) one time only related to morbid obesity;A review of Resident 1's physician progress note dated [DATE] indicated, Assessment & Plan.Venous Stasis Edema W [with] Inflammation [the reddening and swelling of a body part as a reaction to injury or infection] of Bilat [both] Legs (primary encounter diagnosis) Note: Severe edematous leg edema with chronic inflammation changes. Left more than right leg, Patient is not compliant with leg elevation, which can be uncomfortable for patient.Patient does not walk tends to be sitting most of the day. She is at risk of DVT [deep vein thrombosis, a blood clot in a deep vein, usually in the leg or pelvis, which can cause pain, swelling, and skin changes] given that his [sic] unilateral more affected on the left leg.Hold off on antibiotics until ultrasound is done and or see any improvement with above intervention, patient is afebrile [without fever].A review of Resident 1's care plan initiated on [DATE] indicated a focus on Resident 1's left lower leg edema related to venous insufficiency; however, it did not indicate interventions staff were expected to implement regarding how the left lower leg edema could change Resident 1's mobility or what specific safety measures to implement.A review of all of Resident 1's care plans initiated between [DATE] and [DATE] showed no documented evidence of any use of furosemide, its side effects, and how it related to Resident 1's risk of falls.A review of Resident 1's care plan regarding her left lower leg edema related to venous insufficiency was revised on [DATE] to include .has increased swelling and erythema to LLE [left lower extremity]; pain, ‘achy,' and ‘hot'. but was not revised to include interventions staff were expected to implement regarding how the change in condition could change her mobility or what specific safety measures to implement.A review of Resident 1's Change in Condition Evaluation dated [DATE] at 7:36 p.m., indicated, [Resident 1] had several staff assisting her, 2 on her right side and one on her left side supporting her and attempting to pivot her to the bedside commode when she had an assisted fall to the floor.Most recent weight.307.4 [no unit of measure indicated] Date [weight was obtained] [DATE] at 4:44 p.m. [using a] Scale: Wheelchair.Is a behavioral assessment relevant to the change in condition been reported? Not clinically applicable to the change in condition being reported.List any medication changes made in the past week.Furosemide 20 mg.A review of a hospital Emergency Department (ED) admission information form, dated [DATE], indicated Resident 1 arrived to the ED on via ambulance at 7:45 p.m. with a primary diagnosis of left leg cellulitis (skin infection causing redness, swelling and pain to affected area) and a secondary diagnosis of left fibula [NAME] nondisplaced fracture. Resident 1's chief complaint indicated, Accident from [Facility], staff was attempting to help patient to commode and she slid to the floor.A review of the facility's post-fall review of Resident 1's fall dated [DATE] at 7:49 p.m. indicated, Date and Time of Fall.XXX[DATE] at [7:10 p.m.].[Resident 1] fell on both knees, both legs folded underneath her.[Resident 1 was] Receiving staff assistance with transfer to bedside commode.Was resident using assistive device for ambulation or transfer? No.Resident's footwear at time of fall.Slippers.Resident's behavior last observed prior to fall (Check all that apply).Excited, Agitated, Anxious/Nervous Appearance.Medications given in last 4 hours prior to fall .Diuretic.Has the resident received new medications in the past 7 days that may add to fall risk? Yes.Lasix(R) [furosemide].IDT Review Summary and Recommendations.Resident stated she fell because she wanted her old chair back. Resident with Hx [history] of personality disorder Root cause: Resident without apparent injuries, does have left lower leg redness to which the resident was refusing care/treatment to her leg and refused pillows or elevation. Resident requests to be in a chair/recliner.Resident has requested her old recliner [the one her son purchased for her] chair back multiple times- it is in extreme disrepair as evidence by a deep smell that affects other residents and staff.Resident stands and pivots to her bedside commode and fell.[document was signed on] [DATE].A review of Resident 1's care plans initiated on [DATE] indicated the following:-A focus on Impaired Physical Mobility General indicated, Goal[s].Resident will be able to perform activity within physical limits.Resident will be free of complications of immobility.Resident will maintain normal muscle tone.Resident will maintain safe balance and coordination.Resident will participate in prescribed rehabilitation program.Resident will perform physical activity within prescribed mobility restrictions.Resident will use adaptive techniques to safely transfer and ambulate .[Interventions to assist Resident 1 to meet these goals included] Patient will be monitored for complication such as depression, suicidal thought due to immobility.Patient will be sent out to [hospital] for checking the muscle, bones.Patient will be provided with call light and help instead of walking herself.-A focus on a risk for falls r/t Gait/balance problems indicated, Goal.The resident will not sustain serious injury.[Interventions to assist Resident 1 to meet these goals included] Ensure that [Resident 1] is wearing appropriate footwear (slippers) when ambulating or mobilizing in w/c [wheelchair].A review of Resident 1's care plan with a focus on resident is/has potential to demonstrate.behaviors r/t [related to] poor impulse control was revised on [DATE] to include, [Resident 1] has a preference to use old reclining chair (with foul odor and is dirty) oppose to a new one. She verbalizes being upset with staff due to replacement indicated the following intervention for staff to implement Assess and anticipate resident's needs.toileting needs, comfort level, body positioning, pain etc.A review of a hospital's discharge summary note dated [DATE] at 9:07 p.m. indicated, .[Resident 1] had suffered a fall at skilled nursing facility. [Resident 1] was brought here for work-up and noted to have a left fibula fracture as well as a right lower extremity deep venous thrombosis. [Resident 1] was started on anticoagulation [medical treatment that prevents blood clots] but then developed severe soft tissue hemorrhage [heavy, uncontrolled bleeding] into the left lower extremity.[Resident 1] developed progressive septic shock [a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to a drop in blood pressure and organ failure] with acute renal [kidney] failure despite antibiotics for cellulitis.[Resident 1] on [DATE].died peacefully.During an interview on [DATE] at 12:43 p.m., the DON stated the reason there were so many staff in Resident 1's room was to place her on the commode because Resident 1 stated she had been having pain in her legs. The DON further stated, Knowing what [Resident 1's] pain level was that day, I would have used a [resident lift (a mechanical device used to safely transfer residents with limited mobility)].During an interview on [DATE], at 9:29 a.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 1 had attempted to stand up from the new recliner (the one the facility gave her) chair to use the commode for 5-10 minutes. CNA 1 stated Resident 1 said she was unable to get off the new recliner chair and stand up. CNA 1 stated he went to seek assistance from his co-workers. The Nursing Supervisor (NS) and CNA 2 were available to assist. CNA 1 stated, Each of us put an arm under [Resident 1's] armpit and helped her to stand. It took a couple of times, but when [Resident 1] finally stood she went down.It happened so suddenly, and she was heavy. She fell and landed on her knees hard. CNA 1 stated Resident 1 did not use a walker or wheelchair and did not have one at the time of the fall.During an interview on [DATE] at 10:05 a.m., CNA 2 stated, When I walked in the room on [DATE], [Resident 1] had a look on her face like she was in pain. We each took an arm, and [Resident 1] was finally able to stand. When she started to turn toward the commode, [Resident 1's] knees buckled. We tried to stop the fall, but she was too heavy. She landed on her knees.During an interview on [DATE] at 10:29 a.m., the Nurse Supervisor (NS) stated Resident 1 normally was able to get up on her own. LN 1 stated CNA 1 and CNA 2 needed more help to get Resident 1 off the new recliner, so LN 1 got behind Resident 1 and helped push her up from the recliner. LN 1 stated Resident 1 finally got up but quickly became weak. LN 1 stated, The CNAs tried to catch her, but she was too heavy, so she landed on her knees and cried out in pain.During an interview on [DATE] at 10:45 a.m., the Director of Staff Development (DSD) stated an order was not necessary to use the lift equipment on a resident; however, Physical Therapy normally evaluated each resident prior to use. The DSD also stated a Registered Nurse would also be able to evaluate whether a resident was able to transfer safely. The DSD further stated if three people were attempting to transfer a resident, a total lift (a mechanical device used to safely transfer residents who cannot support their own weight) should be used.During an interview on [DATE] at 12:54 p.m., CNA 1 stated Resident 1 was uncomfortable in the new recliner (the one the facility gave her) and needed help getting up to use the commode even before she fell on [DATE].During an interview on [DATE] at 8:33 a.m., the DON stated the administration of furosemide medication would place a resident at risk for falls due to its side effects of lowering blood pressure, possible dizziness and confusion combined with an urgency and frequency to void. The DON confirmed Resident 1 did not have a care plan for the use of furosemide and one should have been created with the implementation of furosemide on [DATE].During an interview on [DATE] at 8:51 a.m., Family Member 1 (FM 1) stated Resident 1's old recliner was purchased several years ago, and Resident 1 depended heavily on this chair to maintain her independence and to be free of pain. The features of Resident 1's old recliner included: lifted Resident 1 to a standing position, oversized for a bariatric (obese) user, elevated Resident 1's legs, fully reclined Resident 1 to a lying position, and was heated. FM 1 stated these features assisted Resident 1 to feel independent and live pain free. During an interview on [DATE] at 12:24 p.m., the DON stated the care plan created for Resident 1's left lower leg edema should have triggered a care plan to be created for fall risk. The DON further stated though [Resident 1] was independent in transferring to the commode, the pain she had in her leg was enough to make her fall.During a telephone interview and concurrent record review on [DATE] at 2 p.m., Physical Therapist 1 (PT 1) stated he was unable to find any documented evidence that Resident 1 had ever been evaluated by a PT for the safe use of either a walker or a wheelchair.A review of facility policy titled Falls and Fall Risk, Managing, dated 2001, indicated, Based on previous evaluations and current data, the nursing staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling.Resident conditions that may contribute to the risk of falls include.lower extremity weakness.medication side effects.functional impairments.Medical factors that contribute to the risk of falls include.heart failure.balance and gait disorders.Resident-Centered Approaches to Managing Falls and Fall Risk.Examples of initial approaches might include.a rearrangement of room furniture.improving footwear.etc.A review of the facility's policy titled Care Plans, Comprehensive Person-Centered revised [DATE] indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan.reflects currently recognized standards of practice for problem areas and conditions.Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.The interdisciplinary team reviews and updates the care plan.when there has been a significant change in the resident's condition.A review of the facility's policy titled Safe Lifting and Movement of Residents revised [DATE] indicated, .Manual lifting ((the activity involving the use of the human body to lift or support a load) of residents shall be eliminated when feasible. Nursing staff, in conjunction with rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include the following.Resident's mobility (degree of dependency); Resident's size; Weight-bearing ability.Whether the resident is usually cooperative with staff.Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary.

Based on interview and record review, the facility failed to ensure 1 resident (Resident 1) in a census of 86 residents received adequate pain management consistent with nursing standards of practice, the resident's individualized care plan, the resident's preferences, and facility policy. Resident 1 described his pain as severe and stated it was #5-9 (moderate to severe) on the pain scale (Pain Scale: a tool health care professionals utilize to help assess a person's pain; the pain scale is from 0 to 10, where 0 is no pain, and 10 is the worst pain imaginable) and his physician ordered him to receive Hydromorphone (also know as Dilaudid; a narcotic pain medication) 4 mg (milligrams) every 4 hours on a scheduled basis. Licensed nurses did not administer Hydromorphone as ordered by the physician because the facility ran out of the medication; nurses did not consistently access and administer Hydromorphone from the emergency medication supply (known as an e-kit); nursing staff did not notify Resident 1's physician (Physician J) when they were unable to administer his pain medication for a period of 24 hours and intermittently thereafter; the pharmacy did not deliver the medication timely; and nursing staff did not develop, and revise when needed, a person-centered care plan addressing pain for Resident 1. These failures: 1) Caused Resident 1 to experience increased pain, 2) Caused Resident 1 to feel suicidal, hopeless, out of control, angry and depressed, 3) Caused Resident 1 to experience symptoms of narcotic withdrawal, and 4) Prevented Physician J from being aware of the ongoing issues related to Resident 1's Hydromorphone delivery and administration and therefore, potentially prevented him from evaluating and addressing the issue. (Online review of the Mayo Clinic website revealed a pain scale provides a standardized means of measuring pain intensity and severity. Their pain scale follows: .Pain Free = 0; Mild Pain = 1-3 (nagging or annoying but doesn't interfere with daily activities) .Moderate Pain = 4-6 (interferes with daily activities) . Sever Pain = 7-10 (disabling or unable to carry out normal daily activities) Ranges from impacts your social relationships, or sleep to being bedridden or even delirious.) [https://connect.mayoclinic.org/blog/adult-pain-medicine/newsfeed-post/what-to-expect-at-my-pain-medicine-appointment] Findings: During a confidential telephone interview on 1/5/24 at 1:54 p.m., Confidential Family Member (CF) stated the facility did not give Resident 1 his pain medication as ordered. CF stated Resident 1's physician ordered he receive Dilaudid for his pain but staff withheld it and the pharmacy sometimes did not deliver it to the facility. Review of Resident 1's medical record revealed his physician diagnosed him with Diabetes Mellitus (commonly known as diabetes; disease characterized by sustained high blood sugar levels), paraplegia (paralysis that mainly affects the legs- though it can sometimes affect the lower body), amputation (surgical removal) of his left leg below the knee, phantom limb syndrome with pain (syndrome where an individual continues to feel sensations like pain, itching, or movement, in a limb that has been amputated) and chronic pain syndrome. A physician order, dated 9/20/2023, indicated Resident 1 was to receive Hydromorphone (Dilaudid) 4 mg (milligrams), .give 1 tablet by mouth every 4 hours for chronic pain. An additional physician order, dated 10/31/2023, indicated Resident 1 was to receive Hydromorphone 2 mg, .give 2 tablet (sic) [for a total of 4 mg] by mouth every 4 hours for chronic pain. Review of Resident 1's electronic medical record revealed nursing staff documented his pain in the MAR (medication administration report). In October 2023, nursing staff documented Resident 1's pain ranged from approximately zero (no pain) to 7 (severe pain). In November 2023, nursing staff documented on his MAR that his pain ranged from approximately zero to 8 (severe). In December 2023, nursing staff documented on his MAR that Resident 1's pain ranged from approximately 2 (mild pain) to 8 (severe). Review of Resident 1's electronic medical record revealed a nursing care plan (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) for pain was not located in his medical record. Review of facility policy titled, Pain Assessment and Management, subtitled, General Guidelines (revised October 2022) indicated, 1. the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, (and) the comprehensive care plan . Review of Resident 1's medical record revealed the October 2023 MAR that indicated from 10/28/23 through 10/29/23, nursing staff did not give Resident 1 approximately six doses of his scheduled Hydromorphone (representing a time period of approximately twenty-four hours). The following doses were documented as not given: 4 a.m.; the nurse documented, .waiting for supplies ., 8 a.m. the nurse documented, .await for delivery ., 12 noon the nurse documented, .on order ., 4 p.m. the nurse documented, .waiting for supplies ., 8 p.m. the nurse documented, .waiting for supplies ., at midnight the nurse documented the medication was not given and at 3 a.m documented, .waiting for supplies. Review of Resident 1's medical record revealed the November MAR indicated on 11/8/2023, the midnight dose was not given and the nurse documented #9 (no side effects) and #2 (Resident not available). Review of Resident 1's medical record revealed the December MAR that indicated multiple doses of Hydromorphone were not given between 12/11/2023 to 12/14/2023. On 12/11/2023 at 4 p.m., the nurse documented Resident 1's pain scale was #7 (severe) and the rationale for not administering the medication was other. On 12/12/23 at 4 a.m., the nurse documented Resident 1's pain as #7 (severe), Hydromorphone was not given, and the nurse documented at 6:21 a.m. that they were, .waiting for supplies . On 12/13/23, the nurse documented the midnight and 4 a.m. doses were not given due to, Hold med, see progress notes. At 05:55 a.m., the nurse documented that they were, .waiting for supplies . On 12/14/23, the nurse documented the midnight dose was not given; at 00:40 a.m. (forty minutes past midnight), the nurse documented, .Previous LN (licensed nurse) shared . that resident was out of Dilaudid, refill will be process (sic), and supply will be deliver(ed) by midnight. However, no delivery has been made. Contacted pharmacy and spoke with (name), stated that refill has not been processed yet but she will process and will be delivered to the facility by 445am (sic). Per pharmacist, she was unable to give me authorization from the e-kit (emergency medication supply) since the prescription is different . At 1:23 a.m., the nurse documented, .Contacted pharmacy .Refill is (sic) yet to be processed . At 4:20 a.m., the nurse documented, Unable to get any (Hydromorphone) from the e-kit per pharmacy since prescription is different. waiting for delivery . , During an interview on 1/30/2024 at 2 p.m., Licensed Nurse C (LN C) stated the pharmacy delivered medication to the facility daily at approximately 6 a.m., 4:30 p.m., and 10 p.m. but it was sometimes hard getting medications from the pharmacy. She stated if a resident's medication was missing, nursing staff had to call the pharmacy. She stated she had had to make multiple calls (to request the medication) in the past and it occurred on all three shifts (day, evening, and night shifts). When asked why staff needed to make multiple calls, LN C stated she did not know. LN C stated she remembered Resident 1, he had an amputation of he left leg below his knee, he had a heel wound, and he would describe his pain as being, everywhere. She stated Resident 1 was receiving his Dilaudid every four hours but the pharmacy had not delivered it, she had called pharmacy (to request the medication), but it was not delivered. She stated she had to call pharmacy to get a one-time code for access to the e-kit and she was then able to administer the medication. (The e-kit required a pharmacy-provided code in order to access narcotics like Hydromorphone/Dilaudid). During the same interview on 1/30/2024 at 2 p.m., LN C stated other resident's medication were similarly impacted. She stated she had had to call pharmacy for other residents whose medications were missing but the pharmacy failed to deliver them. LN C stated when she called the pharmacy, she spoke directly with a pharmacist (versus general pharmacy staff) because she was more likely to get the medication delivered if she did so. During a telephone interview and concurrent review of email correspondence (from Pharmacist F) on 2/12/24 at 11:20 a.m., Pharmacist F (Pharm F) stated the facility requested Resident 1's Hydromorphone be refilled on 10/27/23 (the day prior to his not receiving Hydromorphone for twenty-four hours), the medication was not delivered until 10/29/23 at 2:30 a.m., and the pharmacy was only able to provide a small supply of ten tablets (the Hydromorphone was on backorder). When asked why the medication was not delivered on 10/28/23, Pharmacist F stated they attempted to fill the full order (versus the ten tablets) and the pharmacy sent out the medication on 10/28/23 at approximately midnight. When asked why nursing staff did not get the Hydromorphone from the e-kit (on 10/28/23), Pharmacist F stated Resident 1's order was for 4 m.g dose tablets and the ekit had only 2 m.g tablets. He stated the nurse could have called the physician for a one-time order (physician order for one dose of medication, versus a scheduled dose) of Hydromorphone (in order to access the e-kit medication) and stated this was common (practice). When asked why nursing staff did not get a new one-time order, Pharmacist F stated he did not know and stated that should have happened. During the same telephone interview and concurrent review of email correspondence on 2/12/24 at 11:20 a.m., Pharm F was asked why the nurse did not give the Hydromorphone on 11/8/23 dose at midnight. Pharm F stated he believed the nurses did not have the medication. During the same telephone interview and concurrent review of email correspondence on 2/12/24 at 11:20 a.m., Pharmacist F was asked about nurses intermittent failures to administer Hydromorphone to Resident 1 from 12/11/2023 to 12/13/2023. Pharm F stated he did not know why nurses did not administer Hydromorphone during this time. He stated the Hydromorphone order was changed to 2 m.g tablets (nurses would give two, 2 mg tablets) in November and was filled and delivered on 11/20/23 and 11/29/23. When asked how many tablets were delivered on 11/29/23, Pharm F stated 118 pills were delivered. When asked how many doses that represented, Pharm F stated about ten days worth and the medication would have run out on 12/11/20 (when nursing staff began documenting that the medication was missing). He stated the facility requested a refill on 12/9/23 and 12/13/23 but the pharmacy had to send a notice to the facility and provider (doctor) on both occasions; the notice indicated no refills remained and another physician order was needed. Pharm F stated the next order the pharmacy saw requested was on 12/14/23 around 12:53 a.m.; the Hydromorphone went out (with a quantity of fifty tablets) and was delivered at 6:30 a.m. on the same day. During a telephone interview on 2/12/2024 at 3:30 p.m., Resident 1 and CF were asked what it was like not receiving his Dilaudid, especially during the 24-hour period on 10/28/23. Resident 1 stated he had lots of pain, had the sweats, felt itchy, and felt like he had hives. He stated he had withdrawal (from his Dilaudid) on top of his pain. Resident 1 stated his pain was always above a 7 (severe), occasionally at a 9, but not below a 5 (moderate). Resident 1 stated missing his Dilaudid doses caused his pain to increase and made him feel like it was a hopeless situation. Resident 1 stated not receiving his pain medication made him feel angry and depressed. He stated he felt out of control and stated, I was at their whim and at their mercy. CF stated Resident 1 talked about suicide due to not getting his pain medication and the resulting increased pain. During the same telephone interview on 2/12/2024 at 3:30 p.m., CF stated she had told the prior DON and Administrator (both no longer at the facility) about Resident 1's suicidal thoughts. She stated she was not sure who they were (their names) as the facility had had multiple DON's over the past month and a temporary Administrator. Online review of the Mayo Clinic website indicated, .Do not .suddenly stop taking opioids (Hydromorphone) .Opioids withdrawal can be dangerous, and symptoms can be severe stop opioids slowly, called a taper. Tapering means slowly lowering over time the amount of opioid medicine you take until you stop completely .Symptoms of opioid withdrawal may include .mood changes such as sadness and depression . Increased pain .Goose bumps on the skin . sweating .Thoughts of suicide . (https://www.mayoclinic.org/diseases-conditions/prescription-drug-abuse/in-depth/tapering-off-opioids-when-and-how/art-20386036). During an interview on 2/13/24 at 11:55 a.m., Licensed Nurse H (LN H) stated she remembered Resident 1 well. She stated he used to take his Dilaudid for pain prn (as needed, not scheduled). He took it so frequently that staff called his physician and got the order changed to scheduled Dilaudid (nursing brought him his Dilaudid every four hours versus waiting for him to request it). LN H stated Resident 1's family member (CF) would sometimes call her to tell her Resident 1 was in pain. When asked if she was aware Resident 1 had felt suicidal when his medication was withheld, she stated she was not aware. During the same interview on 2/13/24 at 11:55 a.m., LN H stated pharmacy medication delivery was an ongoing issue at the facility. She stated nursing staff had to call the pharmacy multiple times for missing medications or refills, especially for narcotics (like Hydromorphone). She stated she would keep calling, they would say they would deliver the medication, but the medication would not come. LN H stated she did not know why they didn't process and send the medication. She stated sometimes the did does not message the pharmacy back (after pharmacy reached out to them). LN H stated she worked at another facility and they had a process where nurses could request a rush med, where a driver would pick up the medication and deliver it within two hours. She stated it would be nice if this facility had such a backup system. During the same interview on 2/13/24 at 11:55 a.m., LN H stated if a resident was out of a medication, nursing could call the pharmacy and access the e-kit (pharmacy would provide a code to access the e-kit). When asked why a nurse might not get a code from the pharmacy, she stated the prescription for the medication may be old and/or the resident needed a new prescription. LN H stated on day shift, a nurse could call the physician and ask for a new order. LN H stated the facility had a lot of registry nurses (provided by a contract service) and they did not always ask for help (if they had an issue) and they did not go the extra length (for their residents). During a telephone interview and concurrent medical record review on 2/14/2024 at 9 a.m., the Director of Nursing (DON) was asked about Resident 1 not being administered his Hydromorphone on 10/28/23. The DON stated Resident 1 missed a total of seven doses of Hydromorphone on 10/28/23 and nursing staff documented he had no pain (on the MAR during that time). She confirmed Resident 1's medical record contained no documentation that he was suicidal, no social service note addressing his being suicidal, and no nursing care plan to address his chronic pain. When asked what should have happened, the DON stated staff should have faxed pharmacy a request a refill, called the pharmacy and documented an estimated time of medication arrival. If the medication was not delivered, staff should have called pharmacy a second time and bumped it up, (notified) the DON or the Administrator, and documented in the record that the physician was notified. The DON stated nursing should have gotten a code to access the e-kit (and get the medication) and she stated there was no reason to go seven dosed without pain medication. During the same telephone interview and concurrent medical record review on 2/14/2024 at 9 a.m., the DON stated there was no progress note (nursing note) from nursing staff documenting why his midnight dose of Hydromorphone was not given on 11/8/23. She stated nursing should have documented the reason. During the same telephone interview and concurrent medical record review on 2/14/2024 at 9 a.m., the DON confirmed Resident 1 did not receive his 12/11/23 Hydromorphone scheduled for 6 p.m. and that nursing documented his pain was #7/10 (severe) at the time. She confirmed he did not receive his Hydromorphone on 12/12/23 at 4 a.m., nursing documented they were waiting for supplies, and his pain was #7 (severe). The DON confirmed Resident 1's Hydromorphone was not given on 12/13/23 at 4 a.m. The DON confirmed on 12/14/23, Resident 1 did not receive his Hydromorphone at midnight and 4 a.m The DON stated her expectation was that nurses needed to do what they needed to do to get the medication and they should bump it up (to leadership for assistance). During the same telephone interview and concurrent medical record review on 2/14/2024 at 9 a.m., the DON was asked if she was aware nursing staff had reported pharmacy deliveries were an ongoing problem at the facility and she stated she did not know (this). When asked if the issue with pharmacy was not resolved in October and continued into December 2023 for Resident 1, the DON stated it was a safe assumption and it appeared the issue had not been resolved. During a telephone interview on 2/21/24 4:30 p.m. and 6:00 p.m., Pharmacist G (Pharm G) stated he was the consulting pharmacist at the facility, dealt primarily with clinical issues, and delivery issues were dealt with on the dispensing side (at the dispensing pharmacy, where Pharm F was located). Pharm G confirmed Resident 1 was not given Hydromorphone for twenty-four hours on 10/28/23 and stated it was an, unfortunate situation that he missed his scheduled medication. When asked what nursing should have done in this situation, he stated that they should have notified the physician, who could have then contacted the pharmacy. During the same telephone interview on 2/21/24 4:30 p.m. and 6:00 p.m., Pharmacist G was asked about nursing staff not accessing the e-kit for Resident 1's Hydromorphone. He stated nursing can access the e-kit twenty-four hours a day and it requires a one-time code. He stated this necessitated a physician prescription which could be a verbal order, followed by a written copy (of the order) within seven days. The pharmacy could call the physician for emergency pharmacy needs. Pharm G confirmed Resident 1's issues with Hydromorphone (delivery) in October were still present in December (approximately two months later). When asked if he was aware of issues with accessing the e-kit, Pharm G stated, no. When asked if he was aware of ongoing delivery issues at the facility, Pharm D stated he was aware, but not of any specific issues. He stated there was turnover at the top (leadership at the facility) and that can happen with leadership issues. During a telephone interview on 2/27/2024 at 9:43 a.m., Physician J was asked if he was aware Resident 1 experienced pharmacy delivery issues with his Dilaudid (Hydromorphone). He stated he was aware it happened one time but did not know it was a routine issue. When asked if he was aware nursing staff had not administered Resident 1 his scheduled Dilaudid for approximately twenty-four hours on 10/28/23, Physician J stated the patient (Resident 1) shared the information with him, but nursing staff had not. When asked if nursing staff should have informed him of this, he stated, of course. Physician J stated nurses lost track of narcotic counts and they called when they ran out (of medication). Physician J was asked if Resident 1's symptoms of sweating, itching, and feeling like he had hives were consistent with narcotic withdrawal symptoms and he confirmed that they were, and stated Resident 1 was dependent on Dilaudid. Physician J was informed nursing staff did not document that they were monitoring for signs of withdrawal during that time and he stated nursing staff should have documented the issue and, escalated it up. Physician J stated if he was not available, they (his group) had an on-call (physician available to take a call) physician and staff could have escalated it up to them (for assistance). When asked if he was aware Resident 1 had felt suicidal at the time, Physician J stated, no. He stated Resident 1 had expressed to him that he was upset and uncomfortable (due to pain). Physician J was informed that Resident 1 and CF stated they had informed the previous DON and Administrator about Resident 1's suicidal ideation's and he stated, I believe them. When asked what his expectation was regarding leadership's knowledge of Resident 1's suicidal ideation, he stated the DON should call pharmacy to uncover the problem. He stated the DON should have called pharmacy when Resident 1 ran out of medications on other occasions as well. Physician J was informed Resident 1 missed multiple dosed of Dilaudid from 12/11/23 through 12/14/23. Physician J stated nursing staff should have used the Dilaudid located in the E-kit. Review of facility policy titled, Pain Assessment and Management, subtitled, Implementing Pain Management Strategies (revised October 2022) indicated, . 4. When opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effects . 5. The following are considered when establishing the medication regimen: .b. Administering medications around the clock . 6. The medication regimen is implemented as ordered. Results of the interventions are documented and communicated directly to the provider (doctor) when appropriate. Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications . Under subtitle, Monitoring and Modifying Approaches, the policy indicated, . 4. If the resident is prescribed opioid analgesics (pain medication), monitor for the following side effects: . b. Physical dependence which causes symptoms of withdrawal when opioid medication is stopped, or a dose is held or missed . Review of facility policy titled, Administering Medication, subtitled, Policy Statement (Revised April 2019) indicated, Medications are administered in a . timely manner, and as prescribed. Under subtitle, Policy Interpretation and Implementation, the policy indicated, .4. Medications are administered in accordance with prescribe orders, including and required time frame . Review of facility policy titled, Provider Pharmacy Requirements, subtitled Policy (dated April 2008) indicated, Regular and reliable pharmaceutical service is available to provide residents with prescription and nonprescription medications, services, and related equipment and supplies . Under subtitle, Procedures, the policy indicated, .D. The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to: .2) Accurately dispensing prescriptions based on authorized prescribe orders 6) Providing routine and timely pharmacy service seven days per week and emergency pharmacy service 24 hours per day, seven days per week .b. Medications which should be promptly available such as . drugs used to treat problems including severe pain . or other severe discomfort are available within 4 hours. Based on interview and record review, the facility failed to ensure 1 resident (Resident 1) in a census of 86 residents received adequate pain management consistent with nursing standards of practice, the resident's individualized care plan, the resident's preferences, and facility policy. Resident 1 described his pain as severe and stated it was #5-9 (moderate to severe) on the pain scale (Pain Scale: a tool health care professionals utilize to help assess a person's pain; the pain scale is from 0 to 10, where 0 is no pain, and 10 is the worst pain imaginable) and his physician ordered him to receive Hydromorphone (also know as Dilaudid; a narcotic pain medication) 4 mg (milligrams) every 4 hours on a scheduled basis. Licensed nurses did not administer Hydromorphone as ordered by the physician because the facility ran out of the medication; nurses did not consistently access and administer Hydromorphone from the emergency medication supply (known as an e-kit); nursing staff did not notify Resident 1's physician (Physician J) when they were unable to administer his pain medication for a period of 24 hours and intermittently thereafter; the pharmacy did not deliver the medication timely; and nursing staff did not develop, and revise when needed, a person-centered care plan addressing pain for Resident 1. These failures: 1) Caused Resident 1 to experience increased pain, 2) Caused Resident 1 to feel suicidal, hopeless, out of control, angry and depressed, 3) Caused Resident 1 to experience symptoms of narcotic withdrawal, and 4) Prevented Physician J from being aware of the ongoing issues related to Resident 1's Hydromorphone delivery and administration and therefore, potentially prevented him from evaluating and addressing the issue. (Online review of the Mayo Clinic website revealed a pain scale provides a standardized means of measuring pain intensity and severity. Their pain scale follows: .Pain Free = 0; Mild Pain = 1-3 (nagging or annoying but doesn't interfere with daily activities) .Moderate Pain = 4-6 (interferes with daily activities) . Sever Pain = 7-10 (disabling or unable to carry out normal daily activities) Ranges from impacts your social relationships, or sleep to being bedridden or even delirious.) [https://connect.mayoclinic.org/blog/adult-pain-medicine/newsfeed-post/what-to-expect-at-my-pain-medicine-appointment] Findings: During a confidential telephone interview on 1/5/24 at 1:54 p.m., Confidential Family Member (CF) stated the facility did not give Resident 1 his pain medication as ordered. CF stated Resident 1's physician ordered he receive Dilaudid for his pain but staff withheld it and the pharmacy sometimes did not deliver it to the facility. Review of Resident 1's medical record revealed his physician diagnosed him with Diabetes Mellitus (commonly known as diabetes; disease characterized by sustained high blood sugar levels), paraplegia (paralysis that mainly affects the legs- though it can sometimes affect the lower body), amputation (surgical removal) of his left leg below the knee, phantom limb syndrome with pain (syndrome where an individual continues to feel sensations like pain, itching, or movement, in a limb that has been amputated) and chronic pain syndrome. A physician order, dated 9/20/2023, indicated Resident 1 was to receive Hydromorphone (Dilaudid) 4 mg (milligrams), .give 1 tablet by mouth every 4 hours for chronic pain. An additional physician order, dated 10/31/2023, indicated Resident 1 was to receive Hydromorphone 2 mg, .give 2 tablet (sic) [for a total of 4 mg] by mouth every 4 hours for chronic pain. Review of Resident 1's electronic medical record revealed nursing staff documented his pain in the MAR (medication administration report). In October 2023, nursing staff documented Resident 1's pain ranged from approximately zero (no pain) to 7 (severe pain). In November 2023, nursing staff documented on his MAR that his pain ranged from approximately zero to 8 (severe). In December 2023, nursing staff documented on his MAR that Resident 1's pain ranged from approximately 2 (mild pain) to 8 (severe). Review of Resident 1's electronic medical record revealed a nursing care plan (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) for pain was not located in his medical record. Review of facility policy titled, Pain Assessment and Management, subtitled, General Guidelines (revised October 2022) indicated, 1. the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, (and) the comprehensive care plan . Review of Resident 1's medical record revealed the October 2023 MAR that indicated from 10/28/23 through 10/29/23, nursing staff did not give Resident 1 approximately six doses of his scheduled Hydromorphone (representing a time period of approximately twenty-four hours). The following doses were documented as not given: 4 a.m.; the nurse documented, .waiting for supplies ., 8 a.m. the nurse documented, .await for delivery ., 12 noon the nurse documented, .on order ., 4 p.m. the nurse documented, .waiting for supplies ., 8 p.m. the nurse documented, .waiting for supplies ., at midnight the nurse documented the medication was not given and at 3 a.m documented, .waiting for supplies. Review of Resident 1's medical record revealed the November MAR indicated on 11/8/2023, the midnight dose was not given and the nurse documented #9 (no side effects) and #2 (Resident not available). Review of Resident 1's medical record revealed the December MAR that indicated multiple doses of Hydromorphone were not given between 12/11/2023 to 12/14/2023. On 12/11/2023 at 4 p.m., the nurse documented Resident 1's pain scale was #7 (severe) and the rationale for not administering the medication was other. On 12/12/23 at 4 a.m., the nurse documented Resident 1's pain as #7 (severe), Hydromorphone was not given, and the nurse documented at 6:21 a.m. that they were, .waiting for supplies . On 12/13/23, the nurse documented the midnight and 4 a.m. doses were not given due to, Hold med, see progress notes. At 05:55 a.m., the nurse documented that they were, .waiting for supplies . On 12/14/23, the nurse documented the midnight dose was not given; at 00:40 a.m. (forty minutes past midnight), the nurse documented, .Previous LN (licensed nurse) shared . that resident was out of Dilaudid, refill will be process (sic), and supply will be deliver(ed) by midnight. However, no delivery has been made. Contacted pharmacy and spoke with (name), stated that refill has not been processed yet but she will process and will be delivered to the facility by 445am (sic). Per pharmacist, she was unable to give me authorization from the e-kit (emergency medication supply) since the prescription is different . At 1:23 a.m., the nurse documented, .Contacted pharmacy .Refill is (sic) yet to be processed . At 4:20 a.m., the nurse documented, Unable to get any (Hydromorphone) from the e-kit per pharmacy since prescription is different. waiting for delivery . , During an interview on 1/30/2024 at 2 p.m., Licensed Nurse C (LN C) stated the pharmacy delivered medication to the facility daily at approximately 6 a.m., 4:30 p.m., and 10 p.m. but it was sometimes hard getting medications from [TRUNCATED]

Based on interviews and records review, the facility failed to assess and provide necessary services to prevent the worsening of facility-acquired pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of two sampled residents (Resident 1) when Resident 1 was found to have an open wound on her sacrum (the triangular bone just below the backbone) and coccyx (the tailbone) and the facility failed to: 1. Obtain a doctor ' s order for a routine wound treatment when a sacral wound was identified; 2. Assess and document the status of wound perimeter (refers to the surrounding area of the wound edge), wound bed (the base or open area of a wound) and healing progress as part of the pressure ulcer care plan; and 3. Conduct a comprehensive nutritional assessment for Resident 1 according to facility policy on Prevention of Pressure Injuries (localized damage to the skin as well as underlying soft tissue, usually occurring over a bony prominence or related to medical devices). These failures resulted to the worsening of Resident 1 ' s sacral wound as evidenced by the development of thick adherent (a close and persistent attachment) devitalized (also called slough [a yellow, tan, green or brown in color and may be moist, loose, and stringy) necrotic (dead) tissue and an increased in wound size from 0.5 cm. (centimeter- a metric unit of length) x (by) 0.7 cm to 3.3 cm in length, 1.5 cm in width and 0.1 cm in depth. Findings: During a review of the Minimum Data Set (MDS - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) dated 9/29/23, indicated Resident 1 had a short and long term memory problem. Her cognitive (relating to the mental process involved in knowing, learning, and understanding things) skills for daily decision making was severely impaired. The MDS indicated Resident 1 required extensive (resident involved in activity; staff provide weightbearing support [staff supports some of the weight of the resident])) one person physical assistance with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). During a review of the Pressure Ulcer Care Plan initiated on 11/22/23 indicated care plan interventions to include but not limited to: Administer treatments as ordered and monitor for effectiveness; Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD (Medical Doctor); Encourage to reposition self as tolerated; and Nutritional supplement as ordered for wound healing. 1. During a review of the Progress Note dated 11/22/23 at 7:49 p.m. and concurrent interview with Licensed Staff B on 2/08/24 at 11:14 a.m., the progress note indicated Resident 1 was noted with 4.5 cm x 4.5 cm of non-blanchable redness (skin redness that do not fade when a person presses on them) to sacrococcyx area (pertaining to both the sacrum and coccyx) with an open wound measuring 0.5 cm x 0.7 cm., and was treated with Medihoney (a brand name wound and burn gel). When Licensed Staff B was asked if Resident 1 ' s physician gave the order to treat the wound with medihoney, Licensed Staff B stated yes; however, after review of the Physician ' s Order for November 2023 with Licensed Staff B, she stated there was no order written for medihoney on 11/22/23. She stated she got the order herself from the physician and could have forgotten to enter a physician ' s order. Licensed Staff B stated there was a doctor ' s order written on 11/24/23 to cleanse the sacral wound and apply Medi honey every day. During a review of the Treatment Administration Record (TAR) for November 2023 and concurrent interview with Licensed Staff B on 2/08/24 at 11:21 a.m., the TAR indicated an order written on 11/24/24 to cleanse the sacral wound and apply Medihoney every day. Licensed Staff B verified that the initial wound treatment was done on 11/25/23. When Licensed Staff B was asked if she would know if wound treatment was provided to Resident 1 on 11/23/23 and 11/24/23, she stated no. She stated there was no other wound treatment order written on the TAR except for the 11/24/23. During a review and concurrent interview with the Director of Nursing (DON) on 2/08/24 at 1:35 p.m., the Progress Note dated 11/22/23 at 10:00 p.m. indicated Resident 1 ' s sacral wound was treated with Medihoney, however; after review of the Physician ' s order with the DON, the DON verified there was no written treatment order for Resident 1 ' s sacral wound on 11/22/23. When the DON was asked about her expectations form nurses when providing wound treatment to the residents, she stated, nurses cannot dispense any medication without a doctor ' s order. She stated she expected the nurses to obtain a doctor ' s order for any medication prior to medication or treatment administration following the five rights (right patient, right drug, right time, right dose, right route) of medication administration. 2. During a review of the Progress Note dated 11/23/23 at 2:42 p.m., the Progress Note indicated Resident 1 was monitored for pressure ulcer to her sacrococcyx. The Progress Note indicated, No active bleeding and no signs and symptoms of infection noted. During a review of the Progress Note dated 11/24/23 at 3:31 p.m., the Progress Note indicated, Resident 1 was monitored for pressure ulcer. The Progress Note indicated, No signs and symptoms of infection. During a review of the Progress Note dated 11/25/23 at 4:31 p.m., the Progress Note indicated Resident 1 was monitored for pressure ulcer to coccyx. The Progress Note indicated, No active bleeding and no symptoms of infection. During a review of the Progress Note dated 11/26/23 at 3:11 p.m., the Progress Note indicated Resident 1 was monitored for pressure ulcer to sacrococcyx and was repositioned every 2 hours as needed. During a review of the document titled Initial Wound Evaluation & Management Summary dated 11/28/23 indicated Resident 1 had an Unstageable DTI (Deep Tissue Injury - a form of pressure ulcer or pressure sore. A full thickness skin loss in which the base of the ulcer is covered by slough and /or eschar [a necrotic tissue characterized as dry, thick, leathery tissue that is often tan, brown or black]) to her sacrum with the wound measuring 3.3 cm in length, 1.5 cm in width and 0.1 cm in depth. The document indicated the wound had 60% (percent) of thick adherent devitalized necrotic tissue and 40% granulation tissue (reddish connective tissue [made up of cells, fibers, and a gel-like substance that forms on the surface of a wound when the wound is healing]). During a review of the Treatment Administration Record (TAR) for November 2023 and concurrent interview with the Treatment Nurse on 2/08/24 at 12:20 p.m., the TAR for Resident 1 indicated the Treatment Nurse ' s initial on 11/27/28. The Treatment Nurse verified she provided the wound treatment to Resident 1 ' s sacral pressure ulcer on 11/27/23; however, when the Treatment Nurse was asked if she noted any changes to Resident 1 ' s sacral wound during treatment, she stated no. She stated she would document in Resident1 ' s record if she observed any change. During an interview and concurrent record review with the Treatment Nurse on 2/08/24 at 12:37 p.m., the Treatment nurse stated she had a Progress Note dated 11/28/23 at 2:41 p.m. that Resident 1 was noted with unstageable DTI to her sacrum; however, the Treatment Nurse concurred that her note was based from the wound doctor ' s assessment. When the Treatment Nurse was asked if there were any notes from the nurses indicating Resident 1 ' s sacral wound had worsened prior to the wound doctor ' s visit and that the doctor was notified, she stated no. During an interview with the DON on 2/08/24 at 1:35 p.m., when the DON was asked about her expectations on what the nurses would document when assessing a pressure ulcer, the DON stated she expected for the nurses to document how the wound bed looked like, any necrotic tissue, slough observed, if it is improving or worsening, any signs of infection, if the wound treatment was effective. The DON stated she expected the nurses to notify the physician for any changes and obtain new treatment order if appropriate. During an interview with Licensed Staff D on 2/15/24 at 11:05 a.m., when Licensed Staff D was asked about the facility ' s practice for skin assessment, Licensed Staff D stated licensed nurses were to conduct a skin assessment on admission then weekly. He stated nurses were to document on the weekly nursing progress note for any new and active skin issues to keep track of any skin improvement or worsening. He stated the Progress Note should describe the condition of the wound including wound measurement, drainage, or bleeding if any, presence of odor, and signs of infection. After review of the Weekly Nursing Progress Note dated 11/26/23 for Resident 1 with Licensed Staff D, Licensed Staff D verified the Progress Note indicated, No new skin issue noted. Licensed Staff D verified the Progress Note did not indicate that Resident 1 had an open wound to her sacrum. During an interview and concurrent record review with Unlicensed Staff E on 2/15/24 at 11:10 a.m., when Unlicensed Staff E was asked how often did the direct care staff check the residents for any skin changes, Unlicensed Staff E stated resident ' s skin was constantly checked when providing incontinence (involuntary or accidental leakage of urine [wee] or feces [poo]) care (assisting a resident to apply or change incontinence products like absorbent pads) and every time shower or bed bath was provided. She stated CNAs (Certified Nursing Assistant) would report to the nurse using the facility ' s Stop and Watch tool (an early warning communication tool that CNAs can use to alert a nurse if they notice something different in a resident ' s daily care routine) if a new or worsening skin issue was observed. After review of the document titled Documentation Survey Report for Resident 1 from 11/23/23 to 11/28/23 with the Unlicensed Staff E, Unlicensed Staff E verified that on 11/25/23, A Stop and Watch alert was created indicating a new skin observation and was reported to the nurse. 3. During an interview and concurrent record review with the Registered Dietician (RD) on 2/08/24 at 1:04 p.m., when the RD was asked about her process when a resident was found to have pressure ulcer, the RD stated she would do a full nutritional assessment and will provide recommendations as needed to assist with wound healing. When the RD was asked if Resident 1 was assessed after she was noted to have sacral pressure ulcer, she stated she was on training with the facility RD prior to Resident 1 ' s hospital transfer. She stated the outgoing RD gave her a list of residents who were being monitored for pressure ulcer which did not include Resident 1. The RD also verified there was no comprehensive nutritional assessment for November 2023 from the previous RD for Resident 1 after the identification of the sacral pressure ulcer on 11/22/23. Review of the Facility policy and procedure titled Prevention of Pressure Injuries revised on April 2020 indicated under Nutrition of the Prevention list to, Conduct a comprehensive nutritional assessment for any resident at risk of pressure injury who is screened to be at risk for malnutrition; and for all adult residents with a pressure injury. Review of the Facility policy and procedure titled Nutritional Assessment revised on December 2011 indicated, The Dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current initial assessment timeframes) and as indicated by a change of condition that places the resident at risk for impaired nutrition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and records review, the facility failed to provide staff supervision for transfer and ambulation to one of two sampled residents (Resident 1) when Resident 1 required extensive (resident involved in activity; staff provide weightbearing support [staff supports some of the weight of the resident]) one-person physical assist with transfers and ambulation and was found lying at the hallway. This failure resulted in Resident 1 sustaining a right femoral fracture (a break in the thigh bone) and subsequently had a significant physical functional (the ability to perform basic and instrumental activities of daily living) decline. Findings: During a review of the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with diagnosis including but not limited to: Diabetes Mellitus (disease that result in too much sugar in the blood); Hypertension (High Blood Pressure); and Neurocognitive Disorder (decreased mental function due to a medical disease other than a psychiatric [relating to mental] illness). During a review of the Minimum Data Set (MDS - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) dated 9/29/23 indicated Resident 1 had a short and long term memory problem. Her cognitive (relating to the mental process involved in knowing, learning, and understanding things) skills for daily decision making was severely impaired. The MDS indicated Resident 1 required extensive one person physical assistance with transfers to and from a bed to a chair (or wheelchair); and ambulation. During a review of the document titled Post-Fall Review dated 10/21/23 indicated Resident 1 was found lying at the hallway on 10/21/23 at 7:00 p.m. The document indicated Resident 1 was last observed lying in bed/sleeping prior to the fall. During an observation of Resident 1 ' s room location on 12/26/24 at 11:02 a.m., Resident 1 ' s room was located at the middle of the hallway away from the nurses ' station. During a review of the Progress Note dated 11/03/23 at 3:09 p.m. indicated Resident 1 complained of right hip pain and a request for a STAT (translates to immediately) X-ray (a type of medical imaging that creates pictures of the bones and soft tissues) was sent to Resident 1 ' s Primary Care Physician (PCP). During a review of the document titled Radiology Interpretation dated 11/11/23 indicated Resident 1 had a right femoral fracture. During a review of the document titled Physical Therapy (PT) Evaluation and Plan of Treatment dated 11/21/23 and concurrent interview with Physical Therapist (PT) on 2/08/24 at 10:31 a.m., the document indicated Resident 1 exhibited a significant functional decline due to a right hip fracture as a result from a fall. The PT stated Resident 1 required maximum assistance with transfers and did not ambulate (walk) during her therapy sessions due to Resident 1 was put on non-weight bearing (NWB -resident must not put any weight through the affected leg or foot) to her right leg and was not able to follow weight bearing precautions due to Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During an interview with Unlicensed Staff A on 12/26/23 at 1:11 p.m., when Unlicensed Staff A was asked how much staff assistance Resident 1 needed to walk and transfer from bed to wheelchair and back to her bed prior to her fall on 10/21/23, Unlicensed Staff A stated Resident 1 required extensive assist with both transfers and ambulation. Unlicensed Staff A stated Resident 1 subsequently became dependent from staff with transfer following her fall and did not ambulate. Unlicensed Staff A also stated Resident 1 spent most of the time in bed after falling. During an interview with Licensed Staff B on 2/08/24 at 11:14 a.m. when Licensed Staff B was asked if Resident 1 could transfer and walk without staff assistance, Licensed Staff B stated no; however, when asked how Resident 1 managed to transfer and walk from her room to the hallway and subsequently was found lying on the hallway on 10/21/23, she stated she did not know what happened. During an interview and concurrent record review with the MDS Coordinator (a nursing professional who helps manage a nursing team in a medical facility) on 2/08/24 at 11:48 a.m., the MDS Coordinator stated Resident 1 required extensive one person physical assistance with transfers and ambulation prior to her fall on 10/21/23. After review of the MDS dated [DATE] with the MDS Coordinator, the MDS Coordinator stated Resident 1 had a decline with her ability to transfer from extensive one person assist to being dependent with staff. The MDS Coordinator also stated Resident 1 did not walk during the seven day observation period (11/19/23 to 11/25/23). Review of the Facility policy and procedure titled Activities of Daily Living (ADL), Supporting revised on March 2018 indicated, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with mobility (transfer and ambulation, including walking)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's (Facility 1) Governing Body did not ensure Administrator A followed facility policies for safe discharge when one resident (Resident 1), out of a census of 85 residents, was discharged to Facility 2 (an Independent Living home) that did not provide the care he needed. Resident 1 was assessed by the DOR (Director of Rehabilitation) at Facility 1 prior to discharge, and she determined Resident 1 required assistance with medication administration, stand-by assistance (presence of a person within arm's reach to prevent injury) when ambulating with his FWW (front-wheel walker), and Home Health services (physical therapy and occupational therapy for strength training, balance, etc.). Facility 2 provided the following: two meals a day (lunch and dinner) and housecleaning. Facility 1 did not follow the DOR's recommendations, discharging Resident 1 to a facility that did not meet his needs and did so: 1) Without physician's orders (including orders for medications); 2) Without input from the DON (Director of Nursing) and without notifying the DON; 3) Without the assistance of a qualified Social Worker; 4) Without notifying the Ombudsman (resident advocate; representative serving as a liaison between resident and facility; assists with complaint/concern resolution; investigates elder abuse), ; 5) Without consultation of the IDT (Interdisciplinary Team of healthcare professionals including nursing, social workers, pharmacy, and dietary staff); 6) Without ensuring all of his belongings were sent with him; 7) Without following up with him at Facility 2, to ensure he was safe and well; and, 8) Without accurately and completely documenting the discharge process. These failures caused Resident 1 to: 1) Be admitted to a hospital on two occasions; 2) Suffer a seizure in the Emergency Department (ED) on his first hospital visit; 3) Fall and experience knee pain; 4) Feel scared; and 5) Lose some of his belongings. These failures also impaired the review of his discharge process by facility staff and the Department. (Facility 1 is the skilled nursing facility (SNF) from which Resident 1 was discharged . Facility 2 is the Independent Living (IL) facility to which Resident 1 was sent. Hospital 3 is where Resident 1 was sent when he asked for help from a neighbor. Facility 4 is the SNF where Resident 1 currently lives, located down the street from Facility 1). Findings: Review of Resident 1's medical record (Diagnosis Information portion of the admission Record) from Facility 1 revealed he was admitted to Facility 1 on 8/30/21. His diagnoses included epilepsy (disorder of the brain characterized by repeated seizures), intracranial injury (brain injury), osteoarthritis of the right knee (degenerative [wear and tear] joint condition), intermittent explosive disorder (explosive outbursts of anger and violence in which one reacts out of proportion to the situation), cognitive communication deficit (communication difficulty due to cognitive deficit [acquiring knowledge and understanding through thought, experience, and the senses] more than language/speech deficit), unsteadiness on his feet, and repeated falls. During a telephone interview on 4/4/23 at 11:50 a.m., the Ombudsman (resident advocate; representative serving as a liaison between resident and facility; assists with complaint/concern resolution; investigates elder abuse) stated Resident 1 was a Spanish-speaking man who was concerned he would be evicted from Facility 1 in 2021 after he was involved in an, incident. She stated she spoke to Administrator A at that time, and he moved Resident 1 to a room in another hallway (in response to the incident). The Ombudsman stated she received several incident reports involving Resident 1 (since 2021), where Resident 1 inappropriately touched other residents and one staff member. During the same interview on 4/4/23 at 11:50 a.m., the Ombudsman was asked about Resident 1's discharge from Facility 1 on 1/16/23 (almost two years after he was admitted ). The Ombudsman stated Administrator A did not notify her of Resident 1's discharge until after he was already out of the facility. The Ombudsman stated the normal process was for a facility to notify the Ombudsman thirty days prior to a Resident discharge and stated it was, not okay for Administrator A to have notified her after Resident 1 was gone. She stated she did not know where Resident 1 was sent. She stated Resident 1 did not have any family for support. She could not advocate for Resident 1 (since she was not aware of the discharge) and she, would have intervened (had she known Facility 1 was discharging him). During the same interview on 4/4/23 at 11:50 a.m., the Ombudsman stated she spoke to Administrator A after the fact (after discharge on [DATE]) and he stated Resident 1, was agreeable (to the discharge) and with the facility where he was sent (Facility 2). She stated Administrator A told her Facility 2 was a licensed (by the State of California) Board and Care (facility providing room, board, 24-hour staffing and assistance with bathing, dressing, and medication management). During an onsite visit to Facility 4 (Resident 1's current home, at a SNF) on 4/20/23 at 4:05 p.m., Resident 1 was asked about his discharge from the Facility 1 (on 1/16/23). Resident 1 stated Administrator A wanted to discharge him, but he (Resident 1) did not want to go. On the day of discharge, Resident 1 stated he was not told he was being discharged to another facility; he stated he was told he was going on an outing. Resident 1 stated he did not take any of his personal belongings with him because he thought he was going to be returning to Facility 1. He stated he left his legal documents at Facility 1, including his identification and ATM cards. Resident 1 stated these items were never returned to him. He stated the Ombudsman went to Facility 1 to retrieve these items. During the same interview on 4/20/23 at 4:05 p.m., Resident 1 stated he was dropped off in Oakland (approximately thirty-four miles away) at a residence that housed other people in wheelchairs (Facility 2). Resident 1 stated no one prepared meals for them or gave them their medication. Resident 1 stated when he was dropped off, he had no medication at all, and he was unable to take his medication. Resident 1 stated he was scared. During the same interview on 4/20/23 at 4:05 p.m., Resident 1 stated, after a few days at Facility 2, he asked a neighbor for help. He stated the neighbor called 911 for him, and he was picked up and taken to a hospital. Resident 1 stated he spent days at the hospital before being released to his current SNF (Facility 4), where he felt more comfortable. Review of Resident 1's medical record from Hospital 3 (dated 1/31/23 at 8:39 a.m.) revealed an Emergency Department (ED) physician note indicating, History of Present Illness . (Resident 1) with past medical history of prior CVA (stroke) . with dysarthria (difficult to understand his speech) and right sided hemiparesis (weakness or partial paralysis on one side of the body), TBI (traumatic brain injury), and epilepsy (disorder of the brain characterized by repeated seizures), chronic right knee pain, presented to the ED for evaluation of reported chronic right knee pain after recurrent falls according to both EMS (emergency medical services) and patient. Reports he is unable to receive adequate care at his current living facility (Facility 2) .; has phone numbers provided to him from contacts at APS (Adult Protective Services) and CDPH (California Department of Public Health) who he says are attempting to advocate for him. Reports he is not receiving his medication regularly including his seizure meds. Is having difficulty moving around due to right sided motor deficits from last CVA but does not have new weakness . Is able to report he does not have family nearby who can help provided (sic) care for him . Continued review of Resident 1's medical record from Hospital 3 (dated 1/31/23 at 8:39 a.m.) revealed an Emergency Department (ED) physician note titled, Medical Decision Making that indicated, Differential Diagnosis (process where a doctor differentiates between two or more conditions causing a person's symptoms) Breakthrough seizure (sudden, uncontrolled electrical activity burst in the brain causing; causes changes in behavior, movements, feelings and levels of consciousness) .patellar (knee) fracture .epilepsy (neurological [brain and nervous system] disorder causing seizures), seizure disorder, subtherapeutic med levels (medication level too low to produce the intended medical effect), CVA . Patient (Resident 1) reported reaching out to a neighbor for help this morning to call for (sic) ambulance transport, unable to take maintenance meds x 2-3 (for two to three) days and no pain meds for knee pain provided .patient experienced single episode witnessed tonic-clonic (generalized seizure involving unconsciousness and violent muscle contractions; can be life threatening if untreated) seizure in ED .suspect likely breakthrough seizure (due to) . lack of access to AEDs (Anti-epileptic drugs; AEDs are the most commonly used treatment for epilepsy), provided 1g (gram) of Keppra (anti-seizure medication) in the ED . unable to confirm living facility condition for patient . patient having difficulty meeting ADLs (activities of daily living; eating, bathing, taking medications, etc.) for med admin (administration) and mobility, patient admitted to (Hospital 3) for evaluation and placement (living arrangement). During an onsite visit to Facility 1, interview, and concurrent review of Resident 1's medical record on 6/15/23 at 1:15 p.m., the current DON and current Administrator (Administrator JJ) were asked about Resident 1's discharge on [DATE]. The DON stated 1/16/23, was her first day as the Interim DON at Facility 1, and she did not assist with Resident 1's discharge. A physician discharge order was not located in Resident 1's electronic medical record (EMR). When asked if a physician should have written a discharge order prior to Resident 1 leaving, Administrator JJ stated, they should have an order. No communication with the receiving facility (Facility 2) was located in Resident 1's EMR. The DON stated the prior Administrator (Administrator A) may have communicated via email with Facility 2 (no email communication was located or provided). A resident assessment for the appropriateness of moving Resident 1 to a lower level of care (Facility 2) was not located in the EMR. When asked who assessed residents for a lower level of care, the DON stated a physician did the discharge assessment and documented on a provider note (physician note). Review of facility policy titled, Discharging the Resident, subtitled, Preparation (revised 12/2016) indicated, .6.ensure that a transfer summary is completed and telephone report is called to the receiving facility. Under subtitle, Documentation, the policy indicated The following information should be recorded in the resident's medical record: .3. All assessment data obtained during the procedure . Review of policy titled, Discharging a Resident without Physician's Approval (revised 10/2022) indicated, A physician's order is obtained for discharges . During an interview and concurrent document review on 6/15/23 at 3:10 p.m., Licensed Nurse (LN) E stated she was a wound nurse, and she had performed a skin assessment on Resident 1 prior to discharge. LN E confirmed she documented the skin assessment, dated 1/16/23, located in Resident 1's medical record. LN E stated Resident 1 had asked about his medications and belongings, and she told him he needed to ask his nurse about that. During an interview and concurrent document review on 6/15/2023 at 3:45 p.m., LN F was asked if she was Resident 1's nurse on the day he was discharged (1/16/23). LN F stated she was not sure. When asked if she helped him get ready to leave, LN F stated she did not remember. LN F reviewed Resident 1's, Interdisciplinary Discharge Summary (IDT team's documentation of discharge), dated 1/16/23. She confirmed she signed the section titled, Nursing Services and stated she had signed the document, so I was there in the a.m. (day shift). LN F stated the social worker (Assistant D) said Resident 1 was leaving but did not specify a time. LN F stated her day shift ended at 3:30 p.m. Review of Resident 1's medical record titled, Interdisciplinary Discharge Summary, subtitled, Nursing Services (dated 1/16/23) indicated areas on the form were left blank. The line containing, Clinical lab values or diagnostic tests was not completed (it was blank). The line containing, Behavior issues was not completed and was blank (Resident 1's history of intermittent explosive disorder and inappropriately touching female residents/staff was not documented), and the line containing, Medication allergies was not completed. During an interview and concurrent document review on 6/15/23 at 4 p.m., LN L stated she was Resident 1's nurse on the evening shift (from approximately 3:30 p.m. to 11 p.m.). She stated LN F gave her report (shift summary given to the on-coming nurse) and told her Resident 1 was leaving. LN L stated Assistant D spoke some Spanish (Resident 1's primary language), and she took him Assistant D's office to review his medication. She stated Resident 1 expressed understanding of his medication and then waited for his ride. LN L stated Resident 1 was picked up after 4 p.m., and she and Assistant D took him downstairs to meet his ride. LN L stated Resident 1 had his belongings and medications at discharge. When informed there was no documentation by her in the EMR about medication teaching, medication dispensing, or belongings being sent with Resident 1, LN L stated, I should have done that. She stated Assistant D had told her she would do the documentation and told her, not to worry about it. Review of facility polity titled, Discharge Medications (revised 3/2022) indicated, 1. A physician must be contacted for an order to discharge a resident with medications before they will be dispensed . 5. The nurse shall review medication instructions with the resident . 6. The nurse shall complete the medication disposition record, including: a. the resident's name; .d. the name and prescription (Rx) number of each medication, e. the quantity .of each medication; f. the strength of each medication; g. any special instructions; h. telephone numbers for the physician, pharmacy and facility; and i. the signatures of the person receiving the medications and the nurse releasing them . Review of Resident 1's medical record, revealed a document titled, Post-Discharge Plan of Care (dated 1/16/23). Under subtitle, Medications, the document indicated, See attached. No document was attached. Under subtitle, Medication at Discharge (Prescribed and OTC [over-the-counter]), the document indicated, see attached. No document was attached. During a telephone interview on 6/20/23 at 10:44 a.m., Social Worker C (SW C) stated he was Facility 1's Social Worker from 1/16/23 (the day Resident 1 was discharged ) through May 2023. He stated his first two days of employment were spent in orientation, so he did not work with Resident 1. SW C stated Assistant D was an Assistant Social Worker and worked with Resident 1. SW C stated Administrator A asked him to follow-up with Resident 1 after discharge, but he was unsuccessful doing so. SW C stated none of the information located in Resident 1's medical record about the IL (Independent Living) home (Facility 2), where Resident 1 was sent, was correct. SW C stated the business name of Facility 2 was incorrect, the address was incorrect, and the phone number was incorrect. SW C stated he was unable to locate Facility 2 with an internet map search and stated it was, kind of bizarre. SW C stated he called the two contacts (his brother and former caretaker) listed on Resident 1's medical record and neither knew where Resident 1 was located. SW C stated something seemed wrong. SW C stated it was, weird and stated, How do you discharge someone to a place that doesn't exist? SW C stated he reported his inability to follow-up with Resident 1's discharge due to lack of accurate contact information for Facility 2. When asked what Administrator A did about this, SW C stated he did not know. During the same interview on 6/20/23 at 10:44 a.m., SW C stated he received a call from a Social Worker at Facility 4. The Social Worker called to ask how Facility 1 obtained Social Security payments from Resident 1. She stated Facility 4 currently had Resident 1, but they were having issues assisting him with Social Security payments. SW C stated he asked Administrator A about this and was informed by him that Facility 1 was never able to access Resident 1's Social Security payments, and they were never paid by Social Security. SW C stated his facility (Facility 1) paid Resident 1's first month's rent at Facility 2, where Resident 1 was discharged . During the same interview on 6/20/23 at 10:44 a.m., SW C stated he received a call from the Ombudsman who asked about Resident 1's belongings. SW C stated he dug through the office and found a stack of letters belonging to Resident 1 including some items from the Department of Motor Vehicles. SW C stated he found a temporary identification card, his identification and, quite a bit of other letters. SW C stated Resident 1 did not get everything belonging to him at discharge, I gave a lot to the Ombudsman. Review of facility policy titled, Discharging the Resident subtitled, Discharging the resident to home or another long-term care facility (revised 12/2016), indicated, .2. Be careful in packing the resident's personal effects .Review the personal effects inventory with the resident . and have them sign off that they have received all personal effects. During the same interview on 6/20/23 at 10:44 a.m., SW C was asked about Social Services at Facility 1 prior to his arrival on 1/16/23 (staff who would have assisted with Resident 1's discharge). SW C stated that Assistant D was an Assistant Social Worker. When he finished orientation, SW C stated he worked with Assistant D a half day and she left after that. When she returned, SW C stated she resigned. SW C stated Assistant D did not have training (in social work) and he was technically her boss. SW C stated Assistant D was not reliable and did not provide any notes or hand-off information about Resident 1 prior to her resignation. Review of Resident 1's medical record revealed a discharge document titled, Interdisciplinary Discharge Summary, subtitled, Rehab (rehabilitation) Services (dated 1/16/23) that indicated Patient 1, .requires Home Health to improve function, mobility, & strength. Requires w/c (wheelchair) for mobility & FWW (front-wheel walker)/ with SBA (standby assistance) for ambulation. The summary was signed by the Director of Rehabilitation. During a telephone interview on 6/23/23 at 11:15 a.m., the Director of Rehabilitation (DOR) stated she remembered Resident 1, and he had been her patient. The DOR stated she worked with Resident 1 approximately three times per week. She stated they worked on gait (manner of walking), as he had a tendency to go toward the left side, safety awareness, strength, and standby (staff within arms reach) balance. When asked how Resident 1 was doing with his therapy, the DOR stated, at the time of his discharge, he used a FWW (walker with wheels on the front to provide smoother walking pattern) for ambulation assistance, was able to walk 150 to 200 feet with standby assistance and required one to two breaks during ambulation. The DOR stated Resident 1 required verbal queuing (verbal reminders) when walking; for example, he needed reminders to take smaller steps. During the same interview on 6/23/23 at 11:15 a.m., the DOR was asked about Resident 1's Interdisciplinary Discharge Summary and confirmed she had documented the section titled, Rehab Services, dated 1/16/23. The DOR stated, at the time of discharge, I did request Resident 1 receive Home Health (Physical Therapy and Occupational Therapy) services at his new facility to assist him with navigation of his new environment and space. She stated she recommended he continue with Physical Therapy to improve and be more aware of, and acclimated to, his new surroundings. When asked if Resident 1 received those services at Facility 2, the DOR stated she was, not aware. She stated Resident 1's discharge was, abrupt and she was, not in the loop regarding discharge planning. She stated she was not aware when he was discharged and did not know where he was sent. During the same interview on 6/23/23 at 11:15 a.m., the DOR was asked if she evaluated Resident 1 for a lower level of Care (living at a facility providing fewer services because the resident was more independent). The DOR stated she evaluated Resident 1 for his physical therapy needs, including gait and transferring (example, bed to wheelchair); the DOR stated he needed supervision with these activities. The DOR stated Resident 1 required Physical Therapy and Occupational Therapy for gait, strength training, and balance and stated she communicated these needs to Administrator A and the IDT team. During the same interview on 6/23/23 at 11:15 a.m., when the DOR was informed Resident 1 was discharged to a building without supervision for ambulation or medication administration assistance, she stated, Wow. The DOR stated Resident 1 needed assistance with medication, and he could not make executive decisions, such as higher ADL activities (like medication administration). The DOR stated Resident 1 needed supervision with ambulation and needed Home Health services for PT and OT and he needed supervision with medication administration and could not take his medicine independently. During an email communication on 6/23/2023 at 10:49 a.m., the Community Care Licensing Department was contacted to verify if Facility 2 was a licensed Board and Care or Assisted Living facility. At 3:34 p.m., Technician Q responded via email and indicated, There is no license at that address (Facility 2 ' s address; Facility 2 was not a licensed Board and Care or Assisted Living facility). During a telephone interview on 6/30/2023 at 9:25 a.m., Hospital 3's Social Worker (SW H, who assisted finding Resident 1 a place to live after discharge from the hospital) was asked about Resident 1. SW H stated she assumed Facility 2 was not a licensed AL building as that type of facility was beyond Resident 1's income. SW H stated she consulted with an associate who informed her Facility 2 did not provide meals, medication administration assistance, or supervision. SW H stated she spoke to the owner of Facility 2, and he confirmed Facility 2 was an IL building that did not provide meals, medication assistance, or supervision. SW H stated Facility 2 was, like renting a room. SW H stated she placed Resident 1 into a Board and Care (after his first hospital admission), that provided more services for him. SW H stated Resident 1 lasted one day at that facility because that facility's administrator, couldn't manage Resident 1. Review of Resident 1's medical record from Hospital 3 indicated he was admitted again from 2/14/23 through 2/21/23. The physician ED note titled, HPI (history of present illness), dated 2/14/23, indicated Resident 1 had a history of, .epilepsy, CVA with severe dysarthria (difficulty in speech due to weakness of speech muscles) Present by EMS (via ambulance) with knee pain . Pt (patient) has hx (history of) multi (multiple) falls d/t (due to) chronic right knee pain with difficulty bearing weight on right knee. States he fell today . pt also requesting refill on chronic meds, also wants home health options to help with his meds, meals, states he cannot read. Also requesting a walker . Review of Hospital 3's, Hospitalists' (physicians who cares for patients inside a hospital) SNF/Rehab Discharge Summary (dated 2/21/23), indicated Resident 1 was discharged from Hospital 3 on 2/21/23, to a SNF (Facility 4). During a telephone interview on 6/23/23 at 2:11 p.m., Director of Nursing (DON) J stated she was the DON at Facility 1 from 11/14/22 through 1/13/23 (three days prior to Resident 1's discharge from the facility). When asked what Resident 1's care needs were, DON J stated Resident 1 used a wheelchair, was assisted to the bathroom by staff who waited for him at the bathroom door until he was ready, used the shower with staff help, and required 1:1 staffing (one staff assigned to one resident) due to his behavior of inappropriately touching other residents. DON J stated Resident 1 had not fallen while she was working at the facility. When asked if she thought Resident 1 could cook his own meals, DON J stated, I don't think he could cook. She stated he would only be at eye-level at the stove since he was in a wheelchair. During the same interview on 6/23/23 at 2:11 p.m., DON J stated Administrator A wanted Resident 1 out of Facility 1 because he was costing the facility money with his 1:1 staffing need. DON J stated Administrator A told her to, get rid of this guy because he was taking staff and was an inconvenience. When asked to clarify, DON J stated Administrator A verbalized to her he wished to get rid of Resident 1, and said they had to move, this guy out and find some (other) place. During the same interview on 6/23/23 at 2:11 p.m., DON J was asked about Resident 1's discharge process. DON J stated she had no idea he was being discharged on Monday (1/16/23), three days after her last day (1/13/23). DON J stated discharges went through the Social Services Department and the person acting in that capacity was Assistant D. DON J stated Assistant D was hired as an assistant, had no prior social work experience prior to working at Facility 1, and rarely made it to work. She stated Assistant D had no formal discharge planning training but did a good job. DON J stated she had informal training in the form of consultation with her (the DON) and the prior Social Worker (who was no longer at the facility). During the same interview on 6/23/23 at 2:11 p.m., DON J was asked if Resident 1's discharge was discussed at the IDT (Interdisciplinary Team) meetings. DON J stated, We weren't taking about it in IDT, and if they had been, she or the MDS (Minimum Data Set, assessment tool) nurse would have written a note (in Resident 1's medical record). When asked if nursing was cut out of Resident 1's discharge process, DON J stated nursing (staff and leadership) was not part of his discharge process. When told that Resident 1 had no physician orders in his medical record, DON J stated, Oh, my god, he had to have orders. DON J stated the facility's electronic medical record software made discharges easy. She stated there was a place to click, and the program would take you through the discharge process. She stated the software allowed staff to print the medication list, and nursing would do the medication administration education with the resident. During a telephone interview on 7/5/23 at 12:45 p.m., the owner of Facility 2 (Owner G) was asked about the services provided to residents in his building. Owner G stated his facility was an, Independent Living Group Home (care settings providing housing and limited support services) building and residents had to, help themselves. Owner G stated his facility provided complementary food, including breakfast, lunch, dinner, coffee, and pastries. When asked if he provided medication assistance for residents, he stated, No. When asked if he provided supervision, including supervision for ambulation, he stated, No. When asked if staying at his building was like renting a room, Owner G stated, Yes. Owner G stated he told Administrator A his facility was IL, and not a Board and Care or Assisted Living facility (both of which provided more care for residents). When asked to clarify whether Administrator A was aware he was sending Resident 1 to IL with no supervision and no medication assistance, Owner G stated, Yes, he knows. Owner G stated Resident 1 only stayed a few days at the building. He stated he had some sort of, attack or seizure, a resident called 911, and he was taken to the hospital. During the same interview on 7/5/23 at 12:45 p.m., Owner G stated he went to Facility 1 to assess Resident 1 prior to accepting him to his building. When asked how he had assessed him, Owner G stated he asked him if he could go to the bathroom himself and he said that he could; he asked if he could eat on his own and he said that he could. When asked if he was aware the DOR had recommended Resident 1 needed Physical Therapy and standby assistance when using the walker, as he was a high fall risk, Owner G stated No, I did not know. When asked if he was aware the DOR determined Resident 1 needed assistance with medication administration, Owner G stated, Nobody told me that. Owner G stated, if he had known about Resident 1's medication administration and standby assistance requirements, he would not have accepted him. When asked why, Owner G stated, We don't offer those services. In an email from Community Care Licensing Division (a State department regulating Independent Living facilities), dated 7/12/23, Analyst P wrote, . One of the renters, (at Facility 2) does the cooking . he does prepare lunch and dinner. For breakfast, clients make their own foods from the stocks in the kitchen. Clients interviewed confirmed a that (a resident) cooks and cleans the house. And that they don't get any assistance with ADLs. During a telephone interview on 7/12/23 at 8:45 a.m., Physician K stated he was Resident 1's physician at Facility 1 and confirmed he had medical history of epilepsy, intracranial injury, falls. When asked if his seizures were controlled while at Facility 1, Physician K stated it had been six months (since Resident 1's discharge), and stated he did not know but he was prescribed Phenytoin (antiseizure medication) to help control them. During the same interview and concurrent record review on 7/12/23 at 8:45 a.m., Physician K was asked about Resident 1's discharge paperwork titled, Physician's Discharge Summary (signed by Physician K on 1/27/23, eleven days after discharge). A box was checked on the Discharge Summary that indicated, The resident's health has improved sufficiently and no longer needs the services provided by the facility. Physician K was asked how Resident 1's health had improved sufficiently. Physician K stated Resident 1 could self-propel himself in the wheelchair and he could feed himself. He stated he thought Resident 1 could manage a lower level of care. When asked what type of facility would have been appropriate for him, Physician K stated, Assisted Living or Board and Care (not independent living). When asked if he thought Resident 1 could self-administer his own medication safely, Physician K stated he thought so. He stated Resident 1 might not know which medications were which, secondary to his brain injury, and he might have needed some clarification (by someone else). During the same interview on 7/12/23 at 8:45 a.m., Physician K was asked if he wrote discharge orders (they were not located in the medical record). Physician K stated there was, no record of me signing orders, and he stated he did not remember signing [TRUNCATED]

Based on interview and record review, the facility failed to implement its abuse policy and procedure for one resident (Resident 56), when Resident 56 complained to Staff C (Social Worker) of potential abuse by Staff I (Licensed Nurse) with did not utilitze this knowledge and implement the facility's abuse policies. This failure resulted in Resident 56 not being free from abuse and being subjected to verbal abuse by staff and neglect that lead to anger, humiliation, and physical pain. Findings: During an interview on 5/10/21 at 10:50 a.m., Resident 56 stated that Staff I (License Nurse) called him racial names such as are you Portuguese, are you Chinese, are you Cuban, are you gay? Resident 56 stated that he reported to the Ombudsman (A State official who investigates complaints) and to Staff C. Resident 56 stated this language made him feel angry and racially profiled. During an interview on 5/14/2021 at 10:30 a.m., Staff O (Unlicensed staff) stated that Staff I was very mean to Resident 56. Staff O stated that she heard Staff I called Resident 56 you are cholo [(Mexican associated with street gangs ) Staff O stated that she did not report to Managers (Supervisors) or Administrator because of fear of retaliation. During an interview on 5/14/2021, at 11:40 a.m., Staff C stated he was the social worker. Staff C stated Resident 56 vocalized to Staff C a complaint of abuse concerning Staff I. Staff C stated he did not escalate this complaint to facility administration. Staff C stated that he did not write an abuse report. When asked why Staff C did not report the complaint, Staff C stated he handled the issue alone. During an interview on 5/14/2021 at 4 p.m., in the Conference Room, Ombudsman stated that on 3/2/21 she had a telephone conversation with Staff C regarding Staff I calling names such as Cuban to Resident 56. Ombudsman stated that Staff C would remove Staff I from Resident 56 care. During an interview on 5/14/2021 at 4:30 p.m., in Administrator's office, Staff A stated that he was not told by Staff C regarding a complaint of verbal abuse. During a review of the facility records, the Abuse Reporting binder in Staff C's office contained reports of abuse investigations, policy and procedures for abuse, training on abuse, as well as mandated reporter training. The binder did not contain a written record of Resident 56's complaint to Staff C about Staff I's potential abuse. A review of facility Policy & Procedure (P&P) titled Staff Responsible for Coordinating/Implementing Abuse Prevention Program 12/2006 revealed The Administrator is responsible for the overall coordination and implementation of our facility's abuse prevention program policies and procedures. A review of facility Policy & Procedure (P&P) titled Abuse Prevention Program revised 8/2006 revealed, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Under #1 Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, . C) Identification of occurrences and patterns of potential mistreatment/abuse. D) The protection of residents during abuse investigations. F) Timely and thorough investigations of all reports and allegations of abuse; G) The reporting and filing of accurate documents relative to incidents of abuse.

Based on interview and record review, the facility failed to report to State Agency an allegation of verbal abuse to the appropriate agencies for one resident (Resident 56), when Resident 56 complained about repeated, offensive communication from a licensed nurse and facility staff did not escalate the concern to the facility administrator or investigate the complaint. This failure resulted in delay of a State Survey Agency and facility investigation into verbal abuse affecting Resident 56, did not ensure Resident 56's safety, and caused feelings of anger, humiliation and racially profiling. Findings: Resident 56 During an interview on 5/10/2021 at 10:50 a.m., Resident 56 stated that Staff I (Licensed Nurse) called him different names. Resident 56 stated that Staff I called him Are you gay, Are you a Portuguese, Are you Chinese? Resident 56 stated that he was angry and that Staff I was racial profiling him. Resident 56 stated that he reported the incident to the Ombudsman and to Staff C (Social Worker). During an interview on 5/12/2021 at 11 a.m., Ombudsman stated that he called Staff C to discuss the alleged verbal abuse by Staff I. Ombudsman stated that Staff C stated that he would not assign Staff I to care for Resident 56. During an interview on 5/14/2021 at 11:50 a.m., Staff C stated that he did not fill out a report or did not investigate the alleged verbal abuse reported by Resident 56. Staff C stated that he did not report to the State Agency the alleged verbal abuse by Staff I. Staff C did not inform the DON (Director of Nurses) and to Staff A (Administrator). Staff C stated that he informed Staff L (staffer) to do not assign Staff I to care for Resident 56. During an interview on 5/14/2021 at 12:20 p.m., Staff L stated that Staff C never told him that Staff I should not care for Resident 56. A record review titled Medication Administration Record (MAR) revealed Staff I cared for Resident 56 during the month of May 2021. A review of facility Policy & Procedure (P&P) titled 12/2006 revealed The Administrator is responsible for the overall coordination and implementation of our facility's abuse prevention program policies and procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure eight residents (Residents 2, 23, 54, 56, 62, 67, 72, 235) were free from verbal abuse and neglect by staff, including Staff I (Licensed Nurse), when: 1) Staff I communicated with residents in ways that caused discomfort to both residents and staff. 2) Staff I intimidated Resident 235 and Resident 54. 3) Resident 2 was afraid to ask Staff I for his as-needed pain medication to manage moderate or severe pain. 4) Six Residents in Resident Council vocalized fear of retaliation from Staff I. 5) Resident 23, Resident 2, Resident 62, Resident 67, and Resident 72 observed nursing staff sleeping during regular work hours at night. These failures resulted in residents feeling humiliated, angry, unwanted, no dignity, ignored and in constant pain due to medication withheld and fear of retaliation from staff and unnecessary illness. Findings: 1) During an interview on [DATE] at 10:50 a.m., Resident 56 stated that Staff I (License Nurse) called him racial names such as are you Portuguese, are you Chinese, are you Cuban, are you gay? Resident 56 stated that he reported to the Ombudsman and to Staff C. Resident 56 stated this language made him feel angry and racially profiled. During an interview on [DATE] at 1:30 p.m., Staff M, a licensed nurse, stated that she heard Staff I speak very rudely to residents. Staff M stated that her stomach turns when Staff I treated residents rudely. Staff M stated that she noticed Staff I had completed her 9:00 a.m. medication pass at 8:30 a.m. on prior days, which Staff M stated was too soon to finish. Staff M stated that Staff I was constantly sitting in front of a computer in the nurses station. During an interview on [DATE] at 10:00 a.m., Staff Z5 (unlicensed staff) stated that he observed Staff I speaks very rude to residents. Staff Z5 stated that Staff I would not give resident their pain pill right away intentionally. Staff Z5 stated that Staff I would sit in front of computer and ignore the resident. Staff Z5 stated that he confronted Staff I about giving resident's pain medication late. Staff Z5 stated that when Staff I was in a bad mood, she would yell at residents. During an interview on [DATE] at 10:30 a.m., Staff O (Unlicensed staff) stated that Staff I was very mean to residents. Staff O stated that she observed Staff I left medications on top of the bedside table while resident was asleep. Staff O stated that she heard Staff I called Resident 56 you are cholo [(a derogative reference to Mexicans)]. Staff O stated that she did not report to managers because of fear of retaliation. 2) During a concurrent observation and interview on [DATE] at 11:00 a.m., Staff I was located inside Resident 235's room. Staff I stood in front of Resident 235 while he seating on a wheelchair and a bedside table between them. Staff I leaned in closely to the resident, about six-to-eight inches away from the resident's face, and looked down at the resident while holding onto the resident's bedside table. This Surveyor asked Staff I if she was busy caring for Resident 235? Staff I stated, no. When asked to leave the area for a private interview with the resident, Staff I walked away, stomped her feet and made a grunting sound. During an interview on [DATE] at 11 a.m., Resident 54 stated that when he returned from the hospital after surgery, he pressed the call light for help and Staff I entered his room and she said to him Why are you still alive? Resident 54 stated that he felt sad when he heard that. Resident 54 stated that Staff I was mean and full of attitude towards residents. Resident 54 stated that when he asked for his pain medication, Staff I would say, You have to wait. Resident 54 stated that other staff male or female were mean also. Resident 54 stated that he was afraid to report because of retaliation from Staff I. During an interview on [DATE] at 11:10 a.m., Resident 235 (Resident 54's roommate) stated that he heard Staff I say to Resident 54: Why are you still alive? Resident 235 stated that he felt sad and angry after he heard that. Resident 235 stated that he was very afraid of both Staff I and Staff C for retaliation. Resident 235 stated that he was afraid that Staff C would jeopardize his ability to transfer to another other facility. In regard to the observation of Resident 235 made on [DATE] at 11:00 a.m., Resident 235 stated Staff I had asked him what he intended to share with the state during its annual recertification survey. 3) During an interview on [DATE] at 2:30 p.m., in Resident Council meeting, Resident 2 stated that he would not trust Staff I with his medication. During an interview on [DATE] at 11:30 a.m., Resident 2 stated that whenever Staff I is on duty to work in his care, his medication cup was always ½ full. Resident 2 stated that his pain pill was always missing. Resident 2 stated that Staff I never give him pain medication. Resident 2 stated that he never received relief from his pain. Resident 2 stated that he just suffered from migraine headaches rather than dealing with Staff I. Resident 2 stated that Staff I argued with him about pain medication, especially when Staff I was in a bad mood. Resident 2 stated that he did not report Staff I to the management because he was afraid of retaliation. Resident 2 stated that he felt ignored and neglected. Resident 2 stated that the facility made him feel unwanted and low class citizen. Resident 2 stated that Staff I was difficult to locate when the resident needed patient care. During a review Resident 2's Medication Administration Record (MAR), dated [DATE], the MAR indicated to be administered as-needed to manage Resident 2's moderate or severe pain. The record indicated that Staff I did not administer any pain medication as-needed. 4) During a confidential interview on [DATE] at 2 p.m., in Resident Council meeting, 10 residents attended. Six residents out of 10 stated that they all fear of retaliation from Staff I. During an observation on [DATE] at 2 p.m., in Resident Council meeting, seven residents were angry about the treatment from all staff, but especially Staff I. Residents felt that when they complain, nothing was done, it was ignored. During an interview on [DATE] at 10:00 a.m., Staff Z5 (unlicensed staff) stated that he observed Staff I speaks very rude to residents. Staff Z5 stated that Staff I would not give resident their pain pill right away intentionally. Staff Z5 stated that Staff I would sit in front of computer and ignore the resident. Staff Z5 stated that he confronted Staff I about giving resident's pain medication late. Staff Z5 stated that when Staff I was in a bad mood, she would yell at residents. During an interview on [DATE] at 10:30 a.m., Staff O (Unlicensed staff) stated that Staff I was very mean to residents. Staff O stated that she observed Staff I left medications on top of the bedside table while resident was asleep. Staff O stated that she heard Staff I called Resident 56 you are cholo [(Mexican associated with street gangs.)]. Staff O stated that she did not report to Managers (Supervisor) & Administrator because of fear of retaliation. During an interview on [DATE] at 9:00 a.m., Staff A (Administrator) stated that he was not aware of the name calling by Staff I to residents. Staff A stated that Staff C (Social Worker) did not inform him of any residents who complained about Staff I's behavior towards them. Staff A stated that he would place Staff I on suspension until further investigation. During an interview on [DATE] at 4 p.m., Staff A stated that Staff I was taken off schedule and that she would not return to work in the facility. A review of Staff I's personnel record revealed that Staff I's LVN was current and expired on [DATE]. Staff I's criminal record was clear, no disciplinary actions. Staff I had one competency training titled Changing and Emptying Ostomy Appliance dated [DATE]. Staff I signed the acknowledgement form titled Job Description/Charge Nurse dated [DATE], which was the same as date of hire. Staff I completed a BLS (Basic Life Support) certification on [DATE]. A review of facility Policy & Procedure (P&P) titled 12/2006 revealed The Administrator is responsible for the overall coordination and implementation of our facility's abuse prevention program policies and procedures. A review of facility Policy & Procedure (P&P) titled Abuse Prevention Program revised 8/2006 revealed, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Under #1 Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, #3 Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our resident. B) Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactions, etc. C) Identification of occurrences and patterns of potential mistreatment/abuse. D) The protection of residents during abuse investigations. F) Timely and thorough investigations of all reports and allegations of abuse; G) The reporting and filing of accurate documents relative to incidents of abuse; A review of the facility P&P titled Recognizing signs and symptoms of abuse/neglect revised 1/2011 revealed Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services immediately. #1 abuse is defined as willful infliction of injury unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. #2 Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. #3 other signs and symptoms or actual abuse/neglect may be apparent. When in doubt, report it. 3) Fractures, dislocations or sprains of questionable origin. B) Signs of actual Physical Neglect: 5) Improper use/administration of medication. 5. Resident 23 was admitted to the facility on [DATE] with medical diagnoses including Diabetes Mellitus according to the facility Face Sheet (Facility Demographic). Resident 23's MDS (Minimum Data Set-An assessment tool) dated [DATE] indicated his BIMS (Brief Interview of Mental Status-A cognition assessment) score was 13, which indicated his cognition was intact. During an interview on [DATE] at 1:26 p.m., Resident 23 stated he had observed staff sleeping at night while on duty in the hallway and the nursing station of the facility. Resident 23 stated he had observed both Licensed and Unlicensed personnel sleeping at night. Resident 67 was admitted to the facility on [DATE] with medical diagnoses including Epilepsy (Seizure disorder), according to the facility Face Sheet (Facility Demographic). Resident 67's MDS dated [DATE] indicated his BIMS score was 14, which indicated his cognition was intact. During an interview on [DATE] at 10:45 a.m., Resident 67 stated he had observed staff sleeping in the hallways at night, while on duty. Resident 67 stated he had complained about it but had continued to see staff sleeping. Resident 2 was admitted to the facility on [DATE] with medical diagnoses including Hypertension (High blood pressure) according to the facility Face Sheet. Resident 2's MDS dated [DATE] indicated his BIMS score was 15, which indicated his cognition was intact. During an interview on [DATE] at 10:53 a.m., Resident 2 stated he had observed both Licensed and Unlicensed personnel sleeping at night while on duty. Resident 2 stated he had observed one Licensed Nurse and three Certified Nursing Assistants sleeping during work hours. Resident 2 stated this affected the way staff provided care, such as not answering call lights timely. Resident 2 also stated, Why should we pay them to sleep here? During an interview on [DATE], at 11:30 a.m., Resident 2 stated that when his call light was not answered, he would walk out from his room and found staff slept in the hallway with their leg up in the chair, some staff slept in resident rooms and other staff slept on resident beds as well as in the day room. Resident 62 was admitted to the facility on [DATE] with medical diagnoses including Absence of Left Leg Below Knee, according to the facility Face Sheet. Resident 62's MDS dated [DATE] indicated his BIMS score was 15, which indicated his cognition was intact. During an interview on [DATE] at 10:54 a.m., Resident 62 stated he had observed five to seven staff sleeping in the dining room and in the couch in the lobby area during the night shift. Resident 72 was admitted to the facility on [DATE] with medical diagnoses including Kidney Failure, according to the facility Face Sheet. Resident 72's MDS dated [DATE] indicated his BIMS score was 12, which indicated his cognition was moderately impaired. During an interview on [DATE] at 2:45 p.m., Resident 72 stated he had observed Unlicensed Staff sleeping in chairs, in the hallways of the facility during the night shift. Resident 72 stated he frequently needed pain medication at night, and since his call light was not answered timely, he went out of his room to try to find assistance, and would frequently see staff sleeping in the hallways or using their personal cell phones while on duty. When asked how he felt about this issue, Resident 72 stated, It feels like they (staff) are not doing their job. During an interview with STAFF A, Administrator, on [DATE] at 2:17 p.m., he stated being aware of complaints made by residents indicating staff slept during the night shift while and duty. According to STAFF A, his plan for improvement included checking with residents to see if this continued to happen. During an interview with STAFF B, Infection Preventionist, on [DATE] at 11:30 a.m., she stated staff were not allowed to sleep while on duty but were allowed to sleep during their breaks and meal times. STAFF B was asked if the facility had a designated area or space for staff to sleep during their breaks and meal times, as she had indicated. STAFF B stated there was no designated area for sleeping. The facility's Employee Handbook dated 9/20 indicated, Gross Misconduct infractions are a direct violation of the Facility's standards of conduct, including: Sleeping during work hours.